Relevant pages in other chapters Complaints, p. 650; Consent, p. 654; Professional standards and ethics; p. 661; The GDC, p. 662; Management skills, p. 692; Hiring and firing staff, p. 694; Clinical governance, p. 714; CPD, p. 714; Clinical audit and peer review, p. 714.
Principal sources GDC guidance on standards in dentistry (updated) www.gdc-uk.org/; RCS Eng Good Surgical Practice www.rcseng.ac.uk/standards/good-surgical-practice/overview; Various at www.rcseng.ac.uk/publications/docs.
A dictionary definition of ‘professionalism’:
‘The occupation which one professes to be skilled in and to follow. A vocation in which a professed knowledge of some department of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it. In a wider sense, any calling or occupation by which a person habitually earns his living’.
How different from this broad definition is medical and dental professionalism? Do we individually profess special skill and knowledge? No—that is transparently defined by our peers by assessment, qualification and registration to effectively prove that we have these properties. In the UK the GDC holds registration lists for all dentists and certain specialists (GMC for oral & maxillofacial surgeons) and similar legal structures exist throughout the world. Royal Colleges, Faculties and Specialist Associations all see a major part of their role as ‘standard setting’ for their areas of expertise. Again, this is repeated throughout the world. It is this concept of a universal sense of commitment to a role that defines medical and dental professionalism, not any individual country’s legal definition of it (which is why professions often constitute the major opposition to dictatorships or other extreme political systems).
A useful definition of medical and dental professionalism for our purposes is international and based on the work of Swick.1 They
Individual and collective professional self regulation lies at the heart of the concept of medical and dental professionalism. That is based on the precept that society trusts us with certain privileges by virtue of the job (in all its aspects) that we do and we maintain that trust by individual high standards of behaviour and collective regulation and remediation or censure of those who fail to live up to those standards. I suspect for many of you this concept is self evident although you may not have considered it in quite these terms. Why does ‘professionalism’ now need to be transparently and didactically taught?
Although the concept of the doctor (and latterly the dentist) as a ‘healer’ goes back into antiquity, the concept of a dual role ‘healer’ and ‘professional’ is relatively new with the emergence of the ‘learned professions’ in the middle ages. Until the 1960s the role and commitment of the healing professional was largely implicit, evolving and supported by the majority of society. During the next 20 years an increasingly critical view of the professions developed among the social sciences, managerial echelons and politicians, documenting failures and questioning its relevance to society. In the 1980s and onward an increasing dominance of either state or corporate sector employers and a diminishing influence of the medical professional is seen. This tended to increase the value of systems to state or corporate sector over the values of healthcare professionalism. However, more recently it has been widely recognized that ‘neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism’1 We therefore give more ‘bang for their buck’ by committing to being professional than any externally imposed system. Given that we, as healthcare professionals, have been disrespected and disenfranchised by these influential groups why should we adhere to the notion of professionalism? Clearly the great and good of the medical and dental political world see it as important—is this just to protect their own status?
Probably not. Individually or collectively we cannot do our jobs without a functioning system to work within. The best way to influence that is to wield the power that comes with the trust afforded by society in general in an organized, unified and responsible fashion. Society needs healers, we are still far and away the most trusted of groups in society. The general public is not happy with their leaders. The bureaucrats (state or corporate) control the marketplace and are blamed for defects in the system. Being a professional is the best way to improve the system and genuinely being professional is what makes you want to improve it—for the betterment of all.
Therefore a better definition might read ‘An occupation whose core element is work based on the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some aspect of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments form the basis of a social contract between the profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society’2
this is a term derived from Gough1 s‘the rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract’. It is a complex mix of the explicit; written, legal or paralegal codes, rules and regulations and the implicit; unwritten, individual and collective senses of obligation and purpose reflecting personal and group codes of ethics and morals. It can have universal and local components (i.e. those applicable internationally and those that are country or locality specific). Importantly it is constantly evolving and seeks to balance society’s expectations of medicine with medicine’s expectations of society.
is the basis of dentistry’s contract with society. In common with medicine it requires placing the interests of patients above those of ourselves (within reason), setting and maintaining standards of competence and integrity and providing expert advice to society on matters of health.
For professionalism to have any effective basis in reality the public must trust in us individually and collectively, this depends on our integrity both individually and collectively. The fact that annual polls consistently place doctors and dentists at the very top of lists in which the public place their trust bears out the fact that this has been the case since the origin of our professions.
This in itself can create problems.
The patient, individual or as a community, is not the customer who is always right. Politicians elected or unelected do not always have the best interests of the population at heart. In situations where we as professionals see this to be the case we are obliged to speak out. This can carry with it accusations of paternalism or politicization.
it is illogical to believe that health is not a political issue—it affects the public good and is a right in most civilizations. It is therefore part of being a professional to express both concerns and potential solutions at systems that fail to deliver what they should for patients. What is counterproductive is the descent into party or partisan politics which is the rightful quagmire of the politician.
Equally a desperate avoidance of the appearance of being paternalistic in the name of political correctness becomes counterproductive if we fail to advise patients what we feel is in their best interests. They are entitled to ignore that advice (providing they are competent to do so) and go elsewhere but they are not entitled to demand that we provide a treatment we genuinely believe is not in their best interest.
The principle standard setting bodies in the UK for dentistry are the GDC, the Specialist Dental Education and Training Board, the Conference of Postgraduate Dental Deans, the Dental Faculties of the Royal Colleges of Surgeons, the Speciality Associations, the British Dental Association and the dental degree awarding Universities. Each of these has a different and sometimes conflicting role and each can be influenced to a greater or lesser degree by government. Each country has its own bodies with variations on the same functions.
All these bodies claim to seek to uphold standards and all to a greater or lesser degree speak for a constituent group. This has the inevitable problem of creating a potential conflict of roles. Each organization has to manage the conflict between altruism and self-interest, professional representation and state or corporate control, public good and a union function.
It has been mentioned that self-regulation is a key principle of professionalism and one which is regularly attacked by state and corporate bodies. The preservation of collective self-regulation carries with it certain obligations on the individual; maintenance of competence, participation in the process of self-regulation, support for the relevant bodies and behaviour that reflects integrity. The collective must demonstrate that individuals falling short of their obligations are corrected.
Re-establishing the primacy of the healthcare professional
will require a renegotiation of the social contract. There are legitimate worries on both sides and advantage is taken of serious failures in professional behaviour to disproportionately undermine the healthcare professional’s viewpoint. The repeated use of Shipman (a GP serial killer), or Karadzic (a psychiatrist mass murderer) as examples reinforces this even though these individuals’ monstrous personality disorders could not have been contained by conventional medical self-regulation.
Balancing needs and wants
Society wants (and needs) healers with a professional mindset. It has to have healthcare professionals using their knowledge and skill to heal, cure and relieve suffering. It wants individual’s competence in discrete areas guaranteed. People want to be involved as patients. They want to see that those they trust behave to high ethical (and arguably moral) standards. It also needs accountability. Professionals want (and need) trust and respect and the acknowledgement that some failings are inevitable. Their expertise should be recognized and made appropriate use of. They should be sufficiently autonomous to act in the best interests of patients (politicians dictating and lawyers second guessing helps no-one). They need reasonable, reliable, validated and trusted regulatory and training processes which they have ownership of. They need adequate resources to care optimally for patients. They need to work in a system which transparently promotes the values society wishes to see in its healthcare professionals; caring, altruism, courtesy and competence.
The best way forward
The Royal College of Physicians and Surgeons of Canada have been involved for many years in a project designed to describe the competencies required of a physician. As you can see these include the role of ‘professional’ although their definition is narrower than that already used as it overlaps with the other CanMEDS roles. This descriptive system has been used extensively by the Royal Colleges in the UK in designing higher training curricula, the Modernising Medical Careers group and the equivalent group for basic postgraduate training in dentistry in the UK.
Most of us never actually took a Hippocratic Oath although many think we did. The statement you read out at graduation will have been a modern day version outlining your commitment to professionalism. It was none the worse for that because at the time it was a marker of how you felt about the profession you were entering. The genuinely wonderful OHCM ed. 7 includes both the old and a new version (pp. 0 & 1) so rather than repeat it (go and buy the book) I’ve included a synopsis of principles and commitments based on a physicians charter.